New Patient registration
Child's Name
*
First Name
Last Name
Child's date of birth
*
-
Day
-
Month
Year
Date
Gender
*
Female
Male
Medical Aid
*
Plan/Scheme name
*
Medical aid no
*
Dependent code
*
Main member
*
PERSON RESPONSIBLE FOR ACCOUNT (or. Main Member)
PERSON RESPONSIBLE FOR ACCOUNT or MAIN MEMBER
*
First Name
Last Name
Relationship to child
*
I.D. Number
*
Residential Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Employer
*
Work address the same
Yes
Work Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Cell no:
*
-
Area Code
Phone Number
Home Tel the same
Yes
Home Tel:
-
Area Code
Phone Number
Work Tel the same
Yes
Work Tel:
*
-
Area Code
Phone Number
Email
*
example@example.com
ALTERNATIVE PERSON RESPONSIBLE FOR ACCOUNT
PERSON RESPONSIBLE FOR ACCOUNT
*
First Name
Last Name
Relationship to child
*
I.D. Number
*
Residential address same as main member
Yes
Residential Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Employer
*
Work Address the same
Yes
Work Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Cell no:
*
-
Area Code
Phone Number
Home Tel same
Yes
Home Tel:
*
-
Area Code
Phone Number
Work Tel same
Yes
Work Tel:
*
-
Area Code
Phone Number
Email same as main member
Yes
Email
*
example@example.com
OTHER CONTACTS
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Child
*
Type a question
We value you as a patient. To prevent any misunderstanding, please note: We do not send accounts to Medical Aid unless requested explicitly by Dr Flett. Fees are charged at Discovery Executive Package Medical Aid rates. If you are not on this plan, your medical aid may not cover the full fee. They pay a benefit based on the cover you have chosen. Please note weekend and after-hour services are charged at higher rates, and rates are dependent on complexity and hours of service. Patients must pay at consultation. Due to increasing bad debt, administration and legal costs, the following conditions apply (office hours): • Invoices are due on presentation • We do not phone medical aids • You are responsible for the settlement of fees charged regardless of whether we do/do not submit the invoice to Medical aid. • If Medical Aid pays you, please pay us within seven days of receipt of payment. • It is advised that you monitor all invoices with your medical aid. We do not ‘write off’ unpaid fees. All accounts in default (as detailed above) are referred to our Attorney for recovery. You will be liable for all costs on an attorney-own client basis. Missed appointments not cancelled within 24 hours will be charged for. These terms and conditions automatically apply to all your dependents, whether listed or not. Your de-identified information may be used for epidemiological, research, or practice business planning and may be passed on in a de-identified format to third parties for further processing. For the accuracy of health care planning, it is important that as much information as possible is included in these analyses and that your participation in this regard is highly appreciated. I understand the implications and agree, where appropriate, to the doctor and practice disclosing my ICD-10 diagnostic code under the conditions described above. I accept these conditions. I confirm that I am not under an administration or insolvency order. I nominate my residential address as recorded alongside to be my domicilium citandi et executandi. I consent to the Magistrate Court's jurisdiction in Durban, notwithstanding the amount of the claim against me. I have read and accepted the terms of use, privacy policy, and sharing of personal information(including email addresses) policy on the drflett.com website in terms of the South African POPI Act. Please note the information collected in this form or any online information collected may be automatically removed once the clinical assessment has been completed to comply with drflett's information privacy policy (Please refer to the Privacy Statement at the bottom menu of drflett.com).
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Name
*
First Name
Last Name
Signed at
*
Date
*
-
Day
-
Month
Year
Date
Submit
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